**4. Learning from outcomes and case examples**

#### **4.1. Fingertip injuries and amputations**

in the form of either a medial plantar flap or a medialis pedis flap, while small defects on the palmar aspect may be covered by local or pedicled flaps such as a thenar, cross finger or neurovascular island flap. Replacement of the pulp may be sufficient with the former if small, but may require a toe pulp transfer if large. The posterior interosseous flap is a good flap to use, since it does not rob the forearm of one of its dual blood supplies, has an extensive coverage area and may even replace bone [32]. It is often used to widen the first web space but can be extended distally to cover just up to the metacarpophalangeal joint. However, it can be used to cover multiple digital and pulp losses by flexing the digits. Alternatively, multiple **digits** can initially be syndactylized and surfaced with a pedicled groin or abdominal flap

**Figure 22.** A 73-year-old lady caught her thumb in the door and sustained a complete amputation as shown. The amputated part was only brought in 24 h later although it was stored in a fridge. All the subcutaneous fat was removed completely and the sterile matrix and hyponychium remained. The skin edges were trimmed. The next step is to fix the remnant bone to the proximal fragment and compress it tight. The nail bed is then meticulously repaired with Vicryl 7/0. The skin is sutured with Ethilon 6/0 as a full thickness graft. Flavine emulsion dressing is applied. A reasonable good

result is obtained and 2-P.D. Returns to at least 5–6 mm.

128 Essentials of Hand Surgery

**Figure 21. A:** severe crushing of all digits in a 56-year-old man**. B:** postdebridement. **C:** a custom-designed abdominal flap to cover the deficit. **D:** the right hand in place. Notice the dependent edema. **E:** 20 days post op, prior to division of the flap.

> These are by far the most common hand injuries seen in the emergency and may range from a simple laceration to a complete amputation of the fingertip. The anatomy of the fingertip may be accessed in many esteemed publications but the basic components that are the bone, the overlying nail bed and the volar pulp. As mentioned before, the scaffold must sustain the structure, thus it is imperative to achieve bony stability. **In children**, it may not be necessary (and even detrimental to the blood supply) to place a Kirschner wire, and up to the age of 5, the amputated part may just be capped on with gentle encircling sutures of 7/0 Vicryl or 6/0 Monosyn depending on the size of the digit (See previous chapter, **Figure 11**). The key is to reinsert the original nail plate or a synthetic material in the eponychial fold—for at least 2 weeks—to maintain it open. **In adults**, of course replantation has the best outcome [34], but if the amputation is through the midpoint of the nail plate, we find a good cosmetic outcome with a much lower learning skill—can be achieved by performing a "cap reattachment" [35], also known as a non-microsurgical attachment, somewhat similar to a composite graft [36]. The basis we believe behind this is that all the three structures are meticulously approximated by fine sutures to provide a continuum of the blood supply, encouraging healing. First, the amputated part is thoroughly cleaned by removing **only** the subcutaneous fat from under the skin and leaving in essence a full thickness skin graft (with the edges trimmed), the bone and the hyponychium with the sterile matrix still attached to it. The bone is then K-wired together and compressed proximally. The nail bed is sutured and lastly the skin is tied over and attached as one would do a full thickness graft (**Figure 22**). A "cap" graft in our experience may be performed for crush injuries with amputations just distal to the lunula (Tamai I or Allen II) with opposition of all the three components of tissue (pulp, nail and bone) as described in [37, 38].

**Figure 23.** Ring full thickness skin graft (FTSG) in an avulsion amputation or a failed replant.

#### **4.2. Digital amputations**

Without doubt, amputations are challenging to the junior as well as the senior surgeon and the difficulty increases the more distal it is. Although replantation is the most obviously best option if it is possible and there are a number of good articles on the technique [34, 39, 40], a revision amputation may be performed with some tips and tricks in mind to maximize the function. In a ring avulsion injury where the skin and subcutaneous tissues are avulsed and the bone plus tendinous structures are intact, or not (Urbaniak II, III), a ring skin graft may be applied (**Figure 23**) and the use of some regenerating agents may prove to be helpful [41]. Wherever possible, the proximal interphalangeal (PIP) joint should be preserved, for a prosthesis is more functional at this level. Replantation of digits with amputations distal to the FDS insertion do better as opposed to zone 2 ones and Urbaniak advocates amputation [42]. In these instances, placing a full thickness skin graft in a ring fashion may be helpful because it is firmly adherent on its base, provides a good cosmetic outcome and is relatively easy to perform. Alternatively, an abdominal flap may be fashioned (**Figure 19**) or a venous flow through free flap, in increasing degrees of difficulty.

tremendously in filling up gaps and aiding the healing process. Restoration of blood supply or minimizing use of the tourniquet is also a tip to remember. In a number of cases of forklift injury to the hand where multiple comminuted fractures occurred in one hand, we used a combination of plates, screws and external fixators to attain rapid stabilization of the skeleton (**Figure 24**). Damaged flexor and extensor tendons were also repaired in the same sitting.

**Figure 24. A,B:** a crushing line of force runs across all four fingers, sparing the ring. **C-E:** miniexternal fixators were applied to the border digits—the index and small, whereas the middle was plated partly also due to extensive comminution. **F, G:**

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she was able to move within a week of the trauma. **H:** fixators removed after 6 weeks and plating remains.

A poor outcome is unintentional and part of a learning curve that a surgeon goes through. There are certain pointers to avoid, which ensure known complications (**Figure 25**) do not

**i.** a poor history, neglecting to ask the mechanism, the ischemic time and if the patient

**iii.** inadequate wound debridement of devitalized and crushed tissue leading to delayed

**v.** insufficient strength of repair of structures (such as nerve, tendon and bony stabiliza-

**iv.** infection causing fibrosis, scarring and contracture, a sure sign of stiffness

**5. Poor functional outcome**

**ii.** insufficient radiographs depicting the extent of injury

tion) to start early active rehabilitation

occur. Amongst these are:

healing and infection

smokes!

#### **4.3. Multiple fractures and soft tissue injuries**

The key is to stabilize the bony structure as sturdily and speedily as possible. Once that is achieved, the soft tissue elements will fall into place and be relatively easier to repair and reconstruct. The servile Kirschner wire may prove to be very useful as do the miniexternal fixators from LINK®. It is extremely useful to master Lister's technique as well as polishing one's skills in applying a (minilocking) plate. We have found using bone grafts (synthetic) may aid

**Figure 24. A,B:** a crushing line of force runs across all four fingers, sparing the ring. **C-E:** miniexternal fixators were applied to the border digits—the index and small, whereas the middle was plated partly also due to extensive comminution. **F, G:** she was able to move within a week of the trauma. **H:** fixators removed after 6 weeks and plating remains.

tremendously in filling up gaps and aiding the healing process. Restoration of blood supply or minimizing use of the tourniquet is also a tip to remember. In a number of cases of forklift injury to the hand where multiple comminuted fractures occurred in one hand, we used a combination of plates, screws and external fixators to attain rapid stabilization of the skeleton (**Figure 24**). Damaged flexor and extensor tendons were also repaired in the same sitting.
